Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Fecal incontinence (FI) is a condition whereby passage of solid or liquid feces through the anal canal is not sufficiently restricted. Sacral nerve stimulation may be an effective treatment alternative for patients with severe FI who do not respond to conservative treatments. However, the procedure carries risks for complications, and it is not effective for every FI patient.
Conditions of Coverage
- Sacral nerve stimulation may be covered only for treatment of a neurological condition or abnormalities of sphincter anatomy that have arisen as a proximate result of an industrial injury or occupational disease that has been accepted on or related to the claim; AND
It must be shown by anorectal manometry that the covered neurological condition or sphincter abnormality is causing anorectal dysfunction; AND
- There must be medical documentation of at least six consecutive months of two-times-per-week episodes of liquid or solid stool incontinence caused by the anorectal dysfunction; AND
- There has been documented failure of, or intolerance to, non-invasive incontinence treatments (such as medications, dietary modification, and biofeedback therapy); AND
- There is medical documentation that there is no other plausible explanation for the fecal incontinence, such as a neuropathy of a non-industrial nature, an anorectal malformation, an injury caused by childbirth, or an infectious or parasitic cause; AND
- A trial stimulation period of at least two weeks’ duration documents that sacral nerve stimulation has reduced episodes of fecal incontinence to half or less of the patient’s baseline frequency.
Sacral nerve stimulation for the treatment of chronic constipation, chronic pelvic pain or any other conditions is not a covered benefit.
Implementation of the Coverage Decision
All requests for sacral nerve stimulation for fecal incontinence require prior authorization.
For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).